Health System Research: Designs and Methods

Tulsi Ram Bhandari

Ph D Scholar

Outlines of presentation IntroductionDevelopment Objective AreasDesigns, methods & techniquesEthical issuesLimitations Conflict of interestconclusion

What is research?Scientific and systematic search for

information on particular subject/issue.

Embedded in epistemological position and theoretical framework.

Collects essential evidence with the help of different research methods.

What is health system research?Part of research/health research,

Results closely linked to health system,

Initially, it was known as health service research,

Development of HSRIn 1967, Division of Research in

Epidemiology and Communication Science (RECS) was established for research works, under WHO.

In 1972, RECS was restructured into Division of Strengthening Health Services (SHS) and Health Services Research responsibilities were transferred to Division of SHS.

Development cont…In 1978, Global Advisory Committee on

Medical Research and Sub-committee on Health Services Research were formed-to achieve “Health For All by the year

2000” andImplement the “Primary Health Care”

approach successfully.

In 1980, WHO recognized and established Health System Research with following mandates- Promotion, coordination and information

exchange in the practice of HSR,

Strengthening of national capabilities for HSR training and development

Support to substantive research in priority areas.

Development cont…

In 2000, Health Policy and System Research was launched to improve the performance of health systems.

First time in 2002, under the umbrella of Health System Research there was initiated a new sub area Public Health System Research by the public health system research interest group (PHSR-IG).

Development cont…

Health system ?It is defined as-

“All the organizations, people and actions whose primary intent is to promote, restore or maintain health.”

(WHO-2000)

Definition of HSR

“the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviours affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations.” 6

Concern of HSR

Prime concern of HSR is to provide information for decision-making that can improve the functioning of the health system.

Concern Areas of HSR5

(2)

(4)

(1) (3)

Objective of HSR

…to provide health managers at all levels, as well as community members, with the relevant information they need to make decisions on health-related issues and problems they are facing.

Importance of HSR It is needed to-

Strengthen the health care.

Work with real field problems

Use variety of research disciplines Apply practical scientific knowledge for

improving health care and health status.

Steps/process of HSRDefine research

problemLiterature

review

Review concepts & theories

Review previous findings

Generate researchquestion/s (?)

Research design

& executive plan

Execute research project

Analyze & interpretresults

Submit report

Dis

sem

inat

e re

sults

Seminar/ workshop

Publication

Research Design

It is considered as a "blueprint" for research, dealing with at least four problems: which questions to study, which data are relevant, how to collect data, and how to analyze and interpret the data.

Designs: HSR

Non-Interventionstudies

Interventionstudies

Exploratory studies

Descriptivestudies

Comparative/Analytical studies

Experimentalstudies

Quasi-experimentalstudies

Pre-post experimentalstudies

Exploratory Studies It is a small-scale study of relatively short

duration, which is carried out when little is known about a situation or a problem.

It may include description as well as comparison.

Approach the problem from different angles at same time (Triangulation).

E.g. piloting studies, small scale comparative studies

Descriptive studies It involves describing the characteristics of a

particular situation, event or case, such as- physical, socio-economic and cultural, behavioural, etc.

It can be carried out on a small or larger scale-1. Small scale: case studies

2. Large scale: surveys/census

(Note: one time data collection)

Comparative or analytical studies

It attempts to establish causes or risk factors for certain problems by comparing two or more groups, some of which have or develop the problem and some of which have not.

It can be carried out as follows-1. Cross-sectional comparative studies

2. Case – control studies

3. Cohort studies

Cross-sectional comparative studies

It is a type of survey focus on describing as well as comparing groups.

Researchers wish to determine the role of independent variable to dependent variable.

(Note: relationship between variables)

Case – control studies Investigator compares one group

among whom the problem that he wishes to investigate is present, and another group called a control or comparison group, where the problem is absent, in order to find out what factors have contributed to the problem.

Case-control designPopulation

Cases

Controls

Risk factor Present

Risk factorabsent

Com

paris

on

Risk factor Present

Risk factorabsent

Present Past (Retrospective study, looking backward)

Cohort studies In a study, a group of individuals that is

exposed to a risk factor (exposed group) is compared to a group of individuals not exposed to the risk factor (non-exposed group).

The researcher follows both groups over time and compares the occurrence of the problem.

Cohort studies designPo

pula

tion

Exposed to risk factors

Not exposed to risk factors

Problem Present

Problem not present

Com

parisonProblemPresent

Problem notpresent

Future Present (Prospective study, looking forward)

Experimental Studies In this study, individuals are randomly

allocated to at least two groups.One group is subject to an intervention,

or experiment, while the other group(s) is not.

The outcome of the intervention is obtained by comparing the two groups.

Experimental studies DesignPopulation

Sampling

SampleRandomization

Experimental group Control group

Data collection Data collection

Manipulation/intervention No manipulation/placebo

Data collection Data collection

Comparison

Quasi-experimental studies It is missing either randomisation or the use of a separate

control group. However, it always includes the manipulation/ intervention.

Study design

Control group before

Study group

Com

parison

Control group after

Study group afterIntervention

Study group before

Comparison

Study group afterIntervention

Pretest-posttest experimental studies It is quite easy to set up because uses only one group. The situation is analysed by comparing before and after the intervention.

Study design

Design Vs Method Design ≠ method of data collection Design ≠ quantitative / qualitative

Design?

Systematic plan/procedure under which a study is carried out.

Method ?

Systematic process of achieving certain ends with accuracy and efficiency, in an ordered sequence of fixed steps.

Methods in HSR

Methods in HSR cont…

Quantitative

Explanation, prediction

Test theories Known variables Large sample Standardized

instruments Often deductive

Qualitative

Explanation, description

Build theories Unknown variables Small sample Observations,

interviews Often inductive

Qualitative vs Quantitative Methods

Relationship b/w Qualitative and quantitative methods in Research

Qualitative studies

Quantitative studies

Themes

Understanding problems &identifying associations withand between contributing factors

Operational definition of variables

Measuring problems &testing hypotheses about contributing factors

Data Collection Techniques

Using available information,Observing, Interviewing,Administering written questionnaire, Focus group discussion, Projective technique,Mapping scaling, and others

Using available informationRoutinely collected data,Secondary data: HMIS, NDHS, Census etcUnpublished record report,PublicationsGrey literature( rarely available published

documents),Newspapers,Case histories, etc

Observing Observation of human behaviours,Observation of objectsTypes of observation-

Participatory vs non-participatory Open vs conceal

Observation tool: checklist Structural Semi-structural

Interviewing High degree of flexibility: In-depth interviewSemi-structural interviewLow degree of flexibility: structural

interviewExit interview, supplementary interview,

etc Interview tools

Guideline Structured schedule

Administering Ways of administering-

Sending by mail/email and receiving by same ways,

Hand-to-hand delivering and later collection,

Gathering respondent and requesting to response and return immediately.

Projective technique (PT)Ask the participant to response the

hypothetical or incomplete question.E.g.

Suppose your child suffered from ARI, what would you do?

If your wife was to propose that you use condoms, you would ...

PT can be combined with other methods: FGD, questionnaire, interview etc

Mapping and Scaling Mapping is a valuable technique for

visually displaying relationships and resources. Process mapping Service mapping

Scaling is a technique that allows researchers through their respondents to categorise certain Variables.

Systematic/extensive reviewOnline available literature reviewPublished documents reviewGrey literature reviewUnpublished document/desk reviewReview focused on analytical question,

etc

Case studiesExamine to a great extent in order to

find out and correct possible errors.Common used case studies techniques

Use systemic rapid assessment toolkit Use conceptual framework Use unstructured questionnaire Participatory observation, etc.

System Review systems review is a technique, used to elicit the situation

(Past and present) of an organization. Common techniques of SR-

Structural review Narrative analysis of selective documents Time and motion analysis Cost analysis Trend analysis Demand and supply analysis Gaps and surplus analysis Disease burden analysis Lot Quality Assurance Sampling(LQAS)

Program EvaluationCommon techniques –

Content analysis: textual analysis both qualitative and quantitative studies Analysis: objective, scopes, outputs/outcome

Cost analysis1. Cost-utility 2. Cost-benefit

3. Cost- effectiveness 4. Cost –minimization Budget analysis

Sources of revenue Areas of expenditure

Program Evaluation cont… Financing analysis

Government financing in health Corporate financing Private financing in health Per-capita health expenditure Catastrophic healthcare/expenditure Role of user fees, etc

Health expenditure= government financing + private expenditure

Demand and supply analysisSupply side intervention Demand side intervention

Institutional Innovation

Financial incentives

Skill development

Improved infrastructure

Providers

Health Services

Consumers/users

Empowerment

Awareness

…

Social Network Analysis (SNA) It is defined as a distinctive set of methods used for

mapping, measuring and analysing the social relationships between people, groups and organizations.

It consists of 3 stages: describing the set of actors and members of the

network; characterizing the relationships between actors;

and analysing the structure of the systems and

generating information…

Meta-AnalysisA systematic method of evaluating

statistical data based on results of several independent studies of the same problem.

Produces a stronger conclusion than can be provided by any individual study.

Useful for quantitative as well as qualitative studies

Ethical issues in HSREthical approval and informed consent,Respect of participants,Autonomy of individual participants,Benefits and risks,Dissemination and publication of results,Unique human nature and implementation of

protocolConflict of interest, …

Limitations of HSR Difficult in randomization and equal participation of

subject, High turnover: retirement, transfer, change, etc Difficult to match with relevance policy and

community’s expectation, Cost and benefits: control and distribution Implementation of results with scare resources Donor interest and influence Access/permission , publication and dissemination of

results

Conflict of Interest in HSR Among research team/s and members. Financial issues and quality of research. Disseminating and publishing of the

results. Maintaining the distance and relationship

with participants. Conflict with government’s regulations,

policies, programs, interests…

ConclusionHSR is a new discipline of research/ health

research.

Health services research, health policy and system research and public health system research are very close terms with health system research.

Health system research is being influenced by global politics and investments rather than its own philosophy.

At last…First Global Symposium on Health

Systems Research (HSR), Was organized in Montreux, Switzerland, 16–19 November 2010

Second Global Symposium is going to be organized from 31st Oct. to 3rd Nov. 2012, Beijing, People's Republic of China.

Thank you!

Development of HSRIn 1967, Division of Research in

Epidemiology and Communication Science (RECS) was established for research works, under WHO.

In 1972, RECS was restructured into Division of Strengthening Health Services (SHS) and Health Services Research responsibilities transferred to SHS.

Development cont…In 1978, Global Advisory Committee on

Medical Research and Sub-committee on Health Services Research were formed-to achieve “Health for All by the year

2000” andImplement the “Primary Health Care”

approach successfully.

In 1980, as per the recommendation of Health Services Research Sub-committee, WHO had recognized Health Service Research as a priority area and established Health System Research.

Development cont…

In 1980, Health System Research was considered as an organization with following mandates- Promotion, coordination and information

exchange in the practice of HSR,

Strengthening of national capabilities for HSR training and development

Support to substantive research in priority areas.

Development cont…

In 1990, Technical Discussions of Forty-Third World Health Assembly finalized the following four major themes/issues in health research- Health systems research, Nutrition research, Research capability strengthening, and Science, research and health care.

Development cont…

In 2000, Health Policy and Systems Research was officially launched with the following objectives : Stimulate the generation and synthesis of

knowledge, encompassing evidence, tools and methods

Facilitate the development of capacity for the generation, dissemination and use of knowledge among researchers, policy makers and other stakeholders

Promote the dissemination and use of knowledge to improve the performance of health systems.

Development cont…

First time in 2002, under the umbrella of Health System Research there was initiated a new sub area Public Health System Research by the public health system research interest group (PHSR-IG).

Development cont…

Supply and demand barriers to utilization of health care

...